Review and comparison of current trends in the postoperative management of tendon repair.

The precision of the Evans/Burkhalter protocol and the work by Silverman and associates exemplify one of the most valuable of all current trends in rehabilitation of the healing tendon. Knowledge of tendon excursion at each level and throughout the range of motion in each joint gives us safe parameters for tendon mobilization. Hand rehabilitation is becoming more of a science while remaining an art. Research into tendon healing, nutrition, anatomy, biomechanics, and physiology gives us a solid basis for our treatment techniques. We now need to replicate studies already performed and quantify more precisely the data we have. Many questions remain unanswered. There is a wide variety in the position of splinting for flexor tendon mobilization under current protocols: What joint positions are optimal and why? The number and frequency of repetitions in early mobilization protocols varies greatly: What number and frequency is more appropriate for which patients? How much tendon excursion will control adhesions, promote healing, and avoid gap formation or elongation of the repair? How much force should we apply passively to maintain or increase joint motion? How soon should we start active motion, and how can we control the strength of those early muscle contractions? Do "place-hold" exercises truly place less tension on the repair site? How soon should we begin resisted exercise, and how much resistance are we applying with each type of exercise? Should blocking exercises be considered resistive? How should tendon management protocols be adapted in the presence of associated injuries? Lack of space has prevented discussion here of recent and needed research in a number of areas, such as the effectiveness and appropriate precautions for the use of ultrasound, iontophoresis, and neuromuscular electrical stimulation in tendon management. The evidence is growing, but we have a long way to go. To improve our clinical results, the trend toward precision must continue and grow.